↵†Division of Cardiology, Mount Sinai Hospital and Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, Box 1030, New York, New York 10029

We thank Dr. Wong for the interest in our study (1) and excellent suggestions. In our initial study wherein we compared the culprit lesion of acute coronary syndrome (ACS) with the target lesions in stable angina (2), positive remodeling (PR), low-attenuation plaques (LAP), and spotty calcification characterized the fateful plaques associated with an acute coronary event. In our subsequent study (3), we reported that PR and LAP plaques predicted higher likelihood of acute coronary events during a short-term follow up of 2 years. In the latter paper, we also analyzed the relationship between spotty calcification and acute coronary events; even though the presence of spotty calcification was 2-fold higher in the eventful compared with uneventful plaques, the difference was statistically not significant. On the basis of this study, we defined high-risk plaque (HRP) as the 2-feature or 1-feature positive plaques with PR and/or LAP in the latest study (1). In addition to the higher likelihood of events arising from HRP, we also observed that the period between the computed tomography (CT) angiography and the cardiac event associated with HRP was significantly shorter than the event arising from non-HRP (1.7 ± 1.8 vs. 3.4 ± 2.4 years, p = 0.0005). We agree with Dr. Wong that the plaque volume, LAP volume, and LAP area/plaque area as obtained in the intravascular ultrasound studies (4) and as presented in our previous study (3) should be included in CT angiographic assessment. However, in our unpublished experience, we have encountered napkin ring sign (5) rather infrequently.

In the serial CT angiographic study, 122 patients after percutaneous coronary intervention were evaluated for clinical indications such as the recurrence of chest pain symptoms, or follow-up per discretion of the physician. We excluded all the patients from serial assessment who had sustained a cardiac event before second CT angiogram was undertaken.

Footnotes

Please note: Dr. Narula has received research support from Philips and GE Healthcare in the form of an equipment grant to institution, unrelated to the current project. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose. Daniel Berman, MD, served as Guest Editor for this paper.

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